Investigations that have arisen from reviews of casualty management in the ongoing conflicts in Afghanistan and Iraq have challenged the standard approach to blood transfusion in hemorrhaging patients. Present recommendations are to ideally transfuse non-red blood cell blood products as indicated by coagulation and other blood tests. In the event that testing is not available or feasible, then clinical judgment is advised with two recommendations. The first is that platelets are usually required after red blood cell (RBC) transfusions of one blood volume (approximately 5 liters of blood loss); and the second is that plasma is not usually required until RBC transfusion of well over one blood volume. Contrary to these recommendations is evidence from these conflicts indicating that delays in plasma transfusion or reduced plasma dosing are associated with increased mortality. Although the evidence is primarily retrospective and at times circumstantial in nature, the relationship between plasma administration and mortality appears to be causation rather than simple association. Matching of injury severity and other important variables does not alter this conclusion. If this conclusion is true, the question becomes whether or not the transfusion practice of patients in a civilian setting should be changed.